Youth in Crisis Form

Status: Original and derived artifacts are available for this document.

Download: pdf

National Runaway Safeline – NCS/1800Runaway
Drop Downs for Pre Chat/Text Form and Youth In Crisis Form
Context:
• Automatically filled means that the software – iCarol pulls this data through and it is
not entered by staff
• Not every field has information, no information is mandatory or required unless
noted.
PRE / CHAT TEXT FORM
Country (dropdown)
• United States
Region (dropdown containing all U.S. States and territories, required).
Postal Code/Zip Code (open text field)
Screen Name (open text field)
Age (Dropdown)
• 10
• 11
• 12
• 13
• 14
• 15
• 16
• 17
• 18
• 19
• 20
• 21
• Adult
Race (select all that apply)
• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White
Ethnicity (dropdown)
• Hispanic or Latino
• Not Hispanic or Latino
Session Topic (dropdown)
• Family Dynamics
• Economics
• Mental Health
• School/Education

• Peer/Social
• Health
• Alcohol/Drug Use
• Judicial System
• Physical Abuse/Assault
• Poverty/Homelessness
• Youth and Family Services
• Sexual Abuse/Assault
• Transportation
• Neglect
• Verbal/Emotional Abuse
• Other
How did you hear about NRS (dropdown)
• Social Media
• Search Engine
• Word of Mouth
• Referred by Social Service Agency
• Previous Contact
• Law Enforcement
• School
• NRS Promotional material
• NRS Runaway Prevention Curriculum
YOUTH IN CRISIS FORM
Volunteer -Staff (dropdown containing all staff)
Name (open text field)
Contact Date (automatically filled)
Start Time (automatically filled)
End Time (automatically filled)
Duration (automatically filled)
Contact Information
Phone (open text field)
Type (dropdown)
• Home
• Work
• Mobile
• Pager
• Other
Address (open text field)
State (dropdown containing all states/territories and an out-of-country option)

City (dropdown of all cities in the selected state)
County (dropdown of any counties in the selected state)
Zip Code (open text field)
Pre-Chat Survey [Live chat contacts only]
Screen Name (open text field)
Race (same options as above)
Age (same options as above)
Sex (drop down)
• Male
• Female
Session Topic (same options as above)
How did you hear about NRS (same options as above)
Caller Profile
Language (dropdown) [Hotline callers only]
• Afrikaans
• Alaskan Native Dialects
• American Indian Dialects
• Chinese
• English
• French
• German
• Italian
• Japanese
• Mandarin
• Other
• Polish
• Portuguese
• Russian
• Spanish
• Swahili
• TDD Line
Interpreter’s ID Number (open text field) [Hotline callers only]
Type of Caller (dropdown)
• Youth
• Youth’s Friend
• Parent
• Relative
• Adult
• Agency

• Police
• Probation Officer
• Other
Caller’s Age (same options as options and additional dropdowns)
• 22
• 23
• 24
• 25+
• Not Provided/Unknown
Caller’s Sex (same options as above)
Caller’s Race (same options as above)
Youth’s Age - if caller is not youth (same options as above)
Youth’s Race - if caller is not youth (same options as above)
Youth’s Sex – if caller is not youth (same options as above)
Youth’s Current Location (dropdown)
• Detention/Police
• Friend
• Greyhound/Bus Station
• Home
• Hospital
• Hotel/Motel
• Other
• Recent Acquaintance
• Refused to Disclose
• Relative
• School
• Shelter
• Street
• Trafficker
• Work
• Unknown to Caller
• Not Provided/Not asked
How Long has Youth Been Gone?
• One Day
• Two Days
• Three Days
• Four Days
• Five Days
• Six Days
• One Week
• Two Weeks
• Three Weeks

• One Month
• Two Months
• Three Months
• Four Months
• Five Months
• Six Months
• Seven Months
• Eight Months
• Nine Months
• Ten Months
• Eleven Months
• One Year or More
• Unknown to Caller
• Unknown to Liner
Has Youth Cross State Lines? (dropdown)
• Yes
• No
• Unknown to Caller
• Unknown to Liner
If yes, what is the state of origin? (dropdown, contains all states and territories)
Has youth previously run away? (dropdown)
• Yes
• No
• Unknown to Caller
• Unknown to Liner
If yes, how man times? (dropdown)
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• More than once
Has youth previously been homeless? (dropdown)
• Yes
• No
• Unknown to Caller
• Unknown to Liner

If yes, indicate how many times? (dropdown)
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10